What does Jersey City have that New York City doesn’t? Two hospitals with Leapfrog Group “A” safety grades

Leapfrog just released its semi-annual hospital safety grades. Incongruities identified in my previous blog posts [here and here] appeared again.

New York City had no A grade hospitals, only four got Bs, and nationally known hospitals such as New York Presbyterian (Columbia and Cornell), New York University, and Mount Sinai received C grades.

Residents of New York City are in luck because several A-rated hospitals are located just across the Hudson River. Four of them—Jersey City’s CarePoint Health-Christ Hospital, Jersey City Medical Center, CarePoint Health-Bayonne Medical Center, and CarePoint Health-Hoboken University Medical Center—aren’t exactly household names, but they scored better on safety than their New York neighbors.

CarePoint has figured out how to achieve a top rating but can’t compare to the numbers of California Kaiser Foundation Hospitals scoring well on multiple Leapfrog evaluations. The current rankings show 19 of 26 Kaiser hospitals in California were A rated.

Lean methodology and patient safety

A recent story in U.S. News & World Report described how a Seattle hospital is taking a systems approach in improving healthcare quality and cutting costs. It said, "Virginia Mason Health System...has looked to adopt many of the much-admired and often-emulated business philosophies from Toyota."

The best-known of those philosophies is the so-called "lean methodology" which is based on eliminating waste and focusing on things that add value.

Attempts to incorporate lean into healthcare have met with varying degrees of success. I blogged about this six years ago and pointed out that a literature review done back then found "significant gaps in the [lean and six sigma] health care quality improvement literature and very weak evidence that [lean and six sigma] improve health care quality."

Randomized prospective trials of lean in medicine are lacking. A recent paper from the Journal of the American College of Radiology found only seven studies on the use of lean in radiology and they showed "high rates of systematic bias and imprecision." The authors concluded there was "a pressing need to conduct high quality studies in order to realize the true potential of these quality improvement methodologies [lean and six sigma] in healthcare and radiology."

In addition to the debatable evidence that lean actually works and the cost and time to develop and implement lean measures, the use of Toyota as a model for quality is also highly questionable.

In 2010, Toyota had recalled more than 9 million vehicles for various defects. Nothing has improved. So far this year Toyota has recalled over 11,654,000 vehicles. The problems included exploding airbags, brake failure, fuel tank defects, and minivan doors opening while cars were in motion.

Having adopted lean methodology in 2002, Virginia Mason is not really a new story. How is it doing?

About as well as Toyota.

In May of this year, the Joint Commission paid a surprise visit to Virginia Mason Medical Center and found 29 instances where the hospital was out of compliance with standards. The Seattle Times wrote that among the problems were not having an adequate infection prevention and control plan, failure to store medication safely, and failure to provide a "care, treatment, services and an environment that pose[d] no risk of an immediate threat to health or safety."

On September 17, Virginia Mason regained full Joint Commission accreditation status, and 6 weeks later the hospital announced that it received an "A" grade for patient safety from the Leapfrog Group.

A hospital that failed a Joint Commission site visit because of multiple safety issues gets an "A" for patient safety in the same year? I discussed problems with the Leapfrog patient safety rankings in a previous post.

And if lean works so well in healthcare, can anyone tell me how does a hospital that has been practicing lean methodology for 14 years achieve 29 Joint Commission citations?

The moon and hospital admissions

A few days ago we had a full moon. A lengthy discussion about the effect of a full moon on hospital admissions took place on Twitter.

Many papers say admissions increase and odd things happen, and many others have found there is no relationship between the phases of the moon and anything that goes on in hospitals.

Someone sent me a link to a paper that a lot of devotees of astrology like to quote. It's called "The influence of the full moon on the number of admissions related to gastrointestinal bleeding," and it appeared in the International Journal of Nursing Practice in 2004.

About that $39.35 charge for holding a newborn baby

By now you've probably heard about the hospital that charged $39.35 for a woman who just had a cesarean section to hold her baby.

The baby's father posted a copy of the bill on Reddit, and it drew over 11,800 comments. The story was also widely circulated on Twitter.

At least one labor and delivery nurse on Reddit and a spokesperson for Utah Valley Hospital where the baby was born stated that the charge was not for holding the baby, but rather it was because an extra nurse had to be brought into the room to watch the baby while the first nurse took care of the mother.

I'm not buying it. The only way to justify charging for the presence of a second nurse would be if she had to be called in from home. If the nurse was already in the hospital which I'm sure she was, the five or so minutes that it would take for her to stand by while the mother holds the baby would surely not take her away from the routine duties of a labor and delivery nurse.

This is especially true for Utah Valley Hospital which delivers about 3600 babies per year. Only about 30% of them or about three per day are born by cesarean section.

And who says a second nurse is even required? Most cesarean sections are performed under epidural or spinal anesthesia. The mothers are awake and perfectly capable of holding a newborn child. An anesthesiologist or nurse anesthetist is always in the room and is primarily responsible for caring for the mother anyway.

Like most hospital charges, the $39.35 figure appears to be the product of some bean counter's imagination. Why $39.35? Why not $39.95 or $68.87?

Apparently Intermountain Healthcare (a system which includes Utah Valley Hospital) has some other interesting billing practices. This is what one Reddit commenter had to say:

Hey, I know this world: we had to pay $700 for our son to stay in my wife's room. Here, I'll explain: my wife was billed $700 per night after her c-section, and my son was also billed $700 per night for his room.

Here's the kicker: they shared the same room!! So, I thought it was a mistake, right? So I called the horrible people at Intermountain Healthcare to point out that they had billed two charges for the same room. They're [sic] response? "We bill each patient for the full room charge." Yep, they billed my wife $700 for her room, and my baby $700 for the same room. They also doubled the nurse charges (even though, again, my baby didn't have his own nurses.)

He refused to pay, and the bill was sent to a collection agency.

Congratulations on the birth of your son.

Why hospital rankings are bogus

At the end of 2015, The Leapfrog Group announced its annual list of America’s top hospitals for quality and safety; 98 hospitals receiving the honor.

Unlike some other hospital rating schemes, Leapfrog’s does not factor in reputation. You won’t find any of the usual suspects on Leapfrog’s list. Instead, Leapfrog uses surveys of hospitals and publicly available quality and safety data.

Leapfrog’s top 98 included 62 urban, 24 rural, and 12 children’s hospitals. Of the 86 urban and rural hospitals, only three were university hospitals—University of California Davis Medical Center, University of California Irvine Medical Center, and University of Tennessee Medical Center.

New York managed to place only one hospital on the Leapfrog list.

Other interesting anomalies are that for several states such as Connecticut, Indiana, and Maryland, no hospitals made the list, and of the 21 California hospitals that did, 17 are Kaiser-affiliated. Looks like Kaiser knows how to play the game.

Hospitals Mess Up Medications in Surgery—a Lot

Yes, that was the inflammatory headline on Bloomberg Business News last week. It is great click-bait, but factually off base because the research it refers to was done at only one hospital.

Here's what the study found. During 277 operations with 3,671 medication administrations observed at the Massachusetts General Hospital, 193 (5.3%) involved a medication error or an adverse drug event. One or more errors or adverse drug events occurred in 124 (44.8%) of the procedures.

In all, 40 (20.7%) adverse drug events were not preventable—for instance, an allergic reaction to a drug that was not known about before. Of the remainder, “32 (20.9%) of the errors had little potential for harm, 51 (33.3%) led to an observed adverse drug event and an additional 70 (45.8%) had the potential [emphasis added] for patient harm."

Sounds bad, but the Bloomberg article goes on to say "While all the errors observed in the study had the potential to cause harm, only three were considered [potentially] life-threatening, and no patients died because of the mistakes. In some cases, the harm lay in a change in vital signs or an elevated risk of infection."

Do doctors charge too much?

We all know that some doctors’ fees are excessive. I have blogged about this myself citing a neurosurgeon’s $117,000 charge for assisting on a case.

We also know that doctor bashing is a popular sport right now.

In an otherwise reasonable article about high-deductible health insurance on Vox.com, reporter Sarah Kliff’s second paragraph read as follows:

The bolded text was hyperlinked to a Washington Post piece about a study that showed wide variations in hospital charges for appendectomies in California. The study was not about physician fees. No matter how difficult the case was, no surgeon would ever have been paid $186,955 for performing an appendectomy.

Yesterday, I twice asked Ms. Kliff to please correct this grossly misleading paragraph. She acknowledged my request that evening, but as of 9 AM today, nothing had been changed.

Even if Ms. Kliff had correctly identified the hospitals as the culprits, using appendectomy as an example of why patients should shop for the lowest prices was a poor choice.

Nearly every patient with appendicitis does not know he has it until he has gone to an emergency room, seen an ED physician, and had some tests. I doubt most people in this situation would A) ask how much it’s going to cost to have an appendectomy and B) decide to go to another hospital for care. The fact is, hospitals are so secretive about their charges that a patient would be unable to comparison shop especially if the emergency department visit occurred outside of normal working hours.

Even trying to find out the charges for elective surgery remains difficult in 2015.

Physicians—particularly surgeons—have taken a lot of heat recently. We don’t need articles like this to inflame patients (and journalists) even more than they already are.

ADDENDUM 9:45 AM 10/15/15

The article was just changed. The bolded mistaken passage was corrected, but the next sentence (underlined in red) remains the same. Still blaming those "really expensive doctors."

Ultrasound selfies? How surveys can mislead

Do you believe that traditional hospitals will be obsolete in the future? A recent survey found that 57% of those polled believed that would happen.

The survey, sponsored by the Intel Corporation, involved 12,000 subjects from the United States and seven other countries around the world.

Here are some other revelations from that survey:

• 84% said they would be willing to share their personal health information to advance and lower costs in the health care system.
• 70% said they were receptive to using toilet sensors, prescription bottle sensors, and swallowed health monitors.
• 53% said they would trust a test they personally administered as much or more than if that same test was performed by a doctor
• 30% of people would trust themselves to perform their own ultrasound. 

That made me laugh. Ultrasonography is one of the most operator-dependent tests in use today. It is not easy to perform, nor is it easy to interpret.
I then began to wonder about the credibility of this survey. Before I retired, I practiced in a typical small town in the northeastern United States. Some patients googled me, and a few searched the Internet for information about their illnesses. But for the most part, it was a technologically unsophisticated population.

I just can't envision most of my patients wanting to share their personal health information, use toilet sensors, or trust tests they did at home. Do their own ultrasounds? Not likely. Many of them did not even know what medications they were on.

After rereading the article about the survey, it occurred to me that the sample may have been flawed.

This sentence stood out. "[The] Intel Health Innovation Barometer was conducted online by Penn Schoen Berland in Brazil, China, France, India, Indonesia, Italy, Japan and the United States." The key word is "online."

This reminded me of a famous survey conducted by a magazine called The Literary Digest, which polled 10 million people and had a response of 2.4 million just before the 1936 presidential election. The magazine had correctly called the previous four presidential winners.

The names of the 10 million people queried were drawn from lists of the magazine's subscribers, owners of automobiles, and those with telephones. The survey predicted a crushing defeat for President Franklin D. Roosevelt at the hands of the Republican nominee, Alf Landon.

Of course, the opposite occurred. Roosevelt won all but 8 electoral vote, a huge landslide. What went wrong? Unlike the prior years, 1936 was the middle of the Great Depression, and this time those who had enough money to subscribe to The Literary Digest, own cars, and have telephones were not a representative sample of those who voted.

Do you think maybe the 12,000 people polled online might not be a representative sample of the general population of the world?

I'm not expecting patients to do their own ultrasounds anytime soon. I think hospitals will be around for a while too.

My grandson survives a visit to the ED

Last weekend, my 16-month-old grandson was at a backyard barbecue with his parents. He had been eating some potato chips when he suddenly stopped breathing and turned blue.

Having had CPR training, my son started rescue breathing and suspecting aspiration, performed toddler airway clearance maneuvers. No obstruction was found. The child slowly awakened but was very drowsy.

Because of the concern for aspiration, an ambulance was called and the child was taken to the nearest hospital.

My son called and told me what happened. My wife and I drove to the hospital, which was 15 minutes from my home, but not one where I knew any staff.

By the time we arrived, child had been in the ED for about 10 minutes. Two nurses were trying to start an IV in his chubby arm, he was crying loudly. We took that to be a very good sign. He had already been examined by a doctor.

After successfully starting the IV, the nurses secured it and calmed down my daughter-in-law. She asked where she could buy a bottle of water. One of the nurses said not to bother and brought her a glass of ice water.

The nurses were gentle and professional, so much so that my wife, who is a former ED nurse, didn't mention that fact until nearly 5 minutes after we got there.

The initial vital signs taken were remarkable for a temperature of 104° F, prompting the emergency physician to suggest that the child probably had suffered a febrile seizure. He ordered a chest x-ray because of the history of possible aspiration.

The boy stopped crying and began to watch a cartoon on his father's iPhone. Soon he was smiling and laughing.

The x-ray was negative, and the fever came down with ibuprofen. I resisted the strong urge to point out that lowering a child's temperature has never been shown to prevent a febrile seizure.

We were all relieved that he was okay.

If you were expecting a tale of mistakes, sloppy nurses, and arrogant doctors, I am sorry to disappoint you.

Several essays, blog posts, and media articles about poor care received by doctors or their family members have recently appeared.

This is not one of them.

PS: The nurses complimented us for not trying to run the show.

Non-English-speaking patients. Lost in translation?

What is one of the rules that medical people comply with the least?

My vote goes to "translation." The rule is that you must use a qualified medical interpreter for any interview or discussion with a patient who does not understand English.

How is lack of understanding defined? It is usually fairly obvious. If you aren't sure whether the patient gets it, he probably doesn't.

Why can't family members act as translators?

There is no guarantee that they will understand what is said or transmit it accurately to the patient.

What are the options?

You can summon a translator from the list of hospital personnel who have volunteered to translate. This works if the language in question is Spanish or maybe French. It's not often useful for Bengali or for most of the 13 or so national languages spoken in Mali.

The Joint Commission says if hospital employees are used, they must be qualified as translators and suggests ways that they can become qualified such as language proficiency testing, training in the practice of interpreting, interpreting experience in a health care setting and knowledge of medical terminology.

One website I found while researching this subject claims that the Joint Commission says all on-site interpreters must undergo an FBI background check. I could not verify this with the JC because its standards are only available if you pay. [Digression: If this is true, it is very interesting since doctors and nurses do not have to undergo FBI background checks.]

Many hospitals do not have formal training for interpreters nor are interpreters always available around the clock.

Sometimes hospital administrators take things too literally. In one hospital I know of, a fully bilingual surgeon was told he could not obtain an operative consent in Spanish (his native language) because he had not been trained as an interpreter.

There also are times when the hospital employee is not up to the task either because of education or attitude.

A hospital can contract with a service to provide interpreters via telephone. The advantages are that the interpreters are qualified and speak many different languages, far more than you might find among hospital personnel.

Among the disadvantages is the awkward nature of these conversations. If you use only one handset, you have to keep passing the phone back and forth and you can't hear what the interpreter is saying.

A two-handset phone set-up is somewhat better, but you have to find it. It is always stored in a different place on each floor of the hospital.

Accessing the service can be time-consuming. You must make an 800 call, log in, wait for the interpreter to join and so on.

Either in person or by telephone, the conversation can be frustrating.

I have had occasion to say something to the interpreter that took 2 minutes only to have the interpreter talk to the patient for 10 seconds. Here's a video example.

But the real problem is lack of true physician-patient interaction. You are both talking to someone else. Telling a patient she has cancer or what the risks and benefits of a procedure are is often accompanied by stunned silence from the patient. You really can't tell how much has been understood.

Also worth noting is that whatever the language, most of the time we then have the patient sign a consent form that is written in English.

You may have figured this out by now—many hospitals don't do any of this very well.

What do you do with a patient who speaks a language that even the telephone interpreter service doesn't provide?

We simply do the best we can. I'm not sure that any interpreter, phone or in person, can really communicate with some of these patients. 

Now that I think of it, I'm not sure how many English-speaking patients understand us either.

Patient falls off OR table: System error or human error?

An anesthetized patient fell to the floor headfirst from an operating room table during a laparoscopic appendectomy in Scotland. The table had been tilted into an extreme head down position to facilitate the operation. Fortunately, no injury occurred.

The Edinburgh Evening News account says that there were 10 staff members in the room at the time the case started, but no one had placed a safety restraint on the patient.

A follow -up story noted that the hospital has experienced 11 other major surgical errors in the last year including two instances of wrong-site surgery and a case in which five swabs were left inside a single patient.

An investigation by the hospital noted that the level of situational awareness of the operating room staff was inadequate, and teamwork and communication were poor. In addition, the safety culture within the operating room was described as not highly attuned to patient safety.

The staff was also distracted by mobile phone use and idle chatter.

Instead of addressing the obvious human errors such as failure to place the safety strap, which in US hospitals is clearly the duty of the circulating nurse, the hospital's plan of correction focused on the following typical system-type corrections:

• Compulsory training of 1200 staff. Although there were 10 staff for a laparoscopic appendectomy (in the US there would be 4, nurse, scrub tech, surgeon, anesthesiologist), I doubt that there are 1200 people working in the operating room of this 570-bed hospital. What will those not working in the OR have to gain from compulsory training? I wonder if anyone considered that 10 staff for an appendectomy is far too many, and that's why there was a lot of idle chatter. Six of the staff had nothing to do until the patient needed to be picked up off the floor.

• A ban on talking at key times during operations. This one will be hard to enforce. Who decides what the key times are? I also don't see what it had to do with the incident since tilting the table would not be considered a key time in the case.

• Daily meetings to improve patient safety. Good luck with that. What on earth are they going to discuss at daily meetings to improve patient safety? I predict that those meetings won't take place for more than 3 or 4 weeks.

• Sanctions for staff who fail to meet the new standards. Also be hard to enforce. How will this be judged?

I would have talked with the nursing staff and asked them whose job it was to place the safety strap. If you want to make a system change, why not clearly specify which staff member is responsible for that action? And how about using a checklist?

Five years ago, the Scottish Patient Safety Program recommended using pre-surgery meetings and checklists to protect patients. The investigation showed that in this hospital, checklists were completed about 10% of the time and often not properly. The staff claimed that they didn't have time to do the checklists. Ten people in the room for an appendectomy and no one has time to complete a checklist?

Next I would have asked the anesthesiologist where he was. Usually the job of adjusting the table is his, and the controls are at the head of the bed. He should have noticed the patient was beginning to slide off the table and intervened.

Finally I would have asked the surgeon just how much head down tilt he needed. I have never even come close to having a patient more than about 30 degrees of head down during a laparoscopic appendectomy.

Patient falling from an OR table—human error.

Wrong site surgery—human error.

Leaving foreign objects inside patients—human error.

The OR staff of every hospital counts instruments and swabs. Wrong-site surgery is 100% avoidable. This hospital had a number of appropriate systems in place. The staff simply disregarded them. Creating more meetings and rules that are unlikely to be followed or make a difference will not solve the problem of a staff with a "can't do" attitude.